Chapter 11

If a patient says to a medical assistant, "I have pain in my right hand when I use the computer," this should be charted in the medical record as

"I have pain in my right hand when I use the computer."

The most appropriate way to terminate an initial interview with the patient is ______

"Is there anything else you would like the doctor to know?"

After preparing a patient for an examination, what should a medical assistant ask or state before leaving a patient?

"Is there anything else you would like your provider to know?"

In most states, children are considered adults when they reach the age of ____

18

What is the age of majority in most states?

18

Within how many days of a request is it considered an acceptable practice to act on a patient's request to inspect and obtain a copy of their medical record?

30

Within how many days of a request is it considered an acceptable practice to charge a reasonable fee to cover the expense for copying supplies and labor?

30

For which reasons is blue the preferred ink color for written documentation?

Blue ink will copy as black. Blue ink is difficult to match.

If a patient states that his reason for visit is a tummy ache, how should you record the chief complaint?

C/O "tummy ache"

Which format of medical records documentation breaks the SOAP format into smaller components?

CHEDDAR

In which of the following ways can a medical assistant ensure that data are accurate?

Check all information carefully. Verify information if in doubt as to its accuracy. Check that all numbers have been copied accurately.

Dating all entries in patient records to show the order in which they are made fits which of the 6 Cs of charting?

Chronological order

Which of the following Cs of charting describe providing all the information needed and is readily understandable to others?

Completeness

Which of the six Cs means "getting to the point"?

Conciseness

Which pieces of information should be documented about telephone calls from a patient?

Conclusions or results Who initiated the call Date and time of call

When a patient's broken wrist is documented in the same area of the medical record as the documentation of her stomach ulcer, what type of record is being used?

Conventional record Source-Oriented Medical Record

Identify the components of a medical history form.

Family medical history Past medical history Social history

Which of the following would be included in a problem list in a Problem-Orientated Medical Record (POMR)?

Family problems Work-related problems Social problems

Which of the following is a guideline that should be followed when releasing medical information?

File a signed and dated authorization in the patient's medical record.

When must patients receive a written notice of privacy practices?

First visit

Identify the pieces of information that may be found in the plan of action.

Follow-up instructions Treatment options Medications

CHEDDAR

Format of medical record documentation that breaks information into smaller components

Which of the following is true regarding a patient chart?

It is a legal document

Why must the original content be legible when a correction is made in a patient's medical record?

It shows no cover-up was intended.

Which of the following are practice policies for having new patients complete registration forms?

Mail them to patients prior to their first visit. Have patients complete forms online before their appointments.

What should be done if there is not enough room near the error to make a correction?

Make a notation near the error as to where the correction may be found.

Problem Oriented Medical Record

Medical record composed of the database; problem list; educational, diagnostic, and treatment plan; and progress notes

Source Oriented Medical Record

Medical record with patient information arranged according to who supplied the data

Which entities commonly perform external audits?

Medicare and Medicaid Managed care organizations Private insurance carriers

An unsafe situation may occur when a patient does not follow medical advice this patient would be considered __________ and the information must be __________.

Noncompliant, documented

Which of the following may be included on a hospital discharge summary?

Surgeries or procedures obtained in the hospital History of present illness Patient instructions for care after discharge

Which of the following is NOT a component of registering a new patient?

Taking the patient's vital signs.

Which of the following organizations reviews patient health records to monitor whether the care provided and the fee charged met accepted standards?

The Joint Commission

Which of the following characteristics allow medical records to be understood?

They are neatly written. They contain up-to-date information. They are accurate.

What should be placed on all information received by fax?

Time Date

How can medical records be used for legal reasons?

To defend a doctor against a malpractice claim To support a patient's malpractice case

Identify the uses of patient health records for education purposes.

To educate healthcare staff about medical conditions To educate patients about treatment plans To educate patients about their health conditions

Audit

To examine and review a group of patient records for completeness and accuracy

Why is it important to label a patient record correctly?

To help avoid filing errors

Patients have which rights concerning the use of their PHI?

To request restrictions on PHI To limit disclosures of PHI

Why are internal chart audits advisable for every medical office?

To verify that the medical records "back up" the charges being billed

Which of the following are duties performed by the medical assistant?

Transcribing dictated provider notes Document telephone calls Post laboratory results in the medical record

Transcription

Transforming spoken notes into accurate written form

Identify information found in the social history of a patient's chart.

Use of alcohol Current job Smoking Exercise

Which of the following help keep handwritten entries neat and easy to read?

Using a good-quality pen Using blue or black ink Making sure handwriting is legible

On a problem list, each "problem" is identified by ______ throughout the record.

a number

When you document problems, be careful to distinguish between signs and symptoms. An example of a sign is __________

a rash

A guideline for releasing medical information is to ________

call the recipient to confirm that all materials were received

Patient medical records are frequently used to evaluate the quality of

care

A medical record is also known as a

chart

In the CHEDDAR format of medical records documentation, the "C" stands for

chief complaint.

The reason for a patient's visit is called the

chief complaint.

Progress note documentation always includes information in ______ order.

chronological

"The patient got out of bed and walked 20 feet without reporting or displaying signs of shortness of breath" is an example of __________ in documentation

clarity

The role the medical assistant plays in patient education is to explain ________

management of the patient's condition as outlined by the practitioner

Each piece of correspondence received by the office should be

marked or stamped with the date it was received.

Which of the following information is found on the patient registration form?

name of the person to contact in an emergency

If a patient dies, the ______ may look through records or authorize their release to a third party.

next of kin estate executor

The information obtained from the physician, examinations, and test results is

objective.

Together, signs and symptoms help clarify a patient's problem and can help lead to a diagnosis. An example of a symptom is ________

pain

Which of the following are symptoms?

pain headache nausea

A patient's illness and the reason for a visit to the medical office are found in the _______

patient medical history

The first document found in a patient's financial record is the _______

patient registration form

Which of the following is necessary to release a patient's record to the patient's insurance company?

patient's written consent

In the CHEDDAR format of documentation, the C section includes

presenting problems.

Each ______ should have a detailed educational, diagnostic, and treatment summary in the record.

problem

Part of creating timely and accurate records is maintaining a(n) ______ tone in your writing when recording information.

professional

Audits that are done by medical staff before patient billing is submitted are ________

prospective internal audits

The A section of SOAP documentation includes _________

the diagnosis of impression of a patient's problem

Continuation of a medical record lasts as long as

the patient is under the doctor's care.

Information about disclosures of a patient's PHI is usually filed in

the patient's medical record.

The chief complaint should be recorded in the medical record using

the patient's own words.

The P section of SOAP documentation is ________

the plan of action

The reason a patient's record should not be sent by fax machine is that _______

there is no way to tell who will see the document

Telephone calls from a patient, and calls the doctor makes to a patient, must be ______.

time and dated documented initialed

Transforming spoken notes into accurate written form is known as

transcription.

When is it appropriate to send the original documents in a patient's health record?

when the record is subpoenaed for a court case

The S section of SOAP documentation is _____

data that comes directly from the patient

The O section of SOAP documentation is ______

data that comes from examination results and from the provider

In a problem-orientated medical record, the ______ is the part of a medical record that includes the patient's tests and procedure results.

database

In the problem-oriented medical record (POMR), which of the following includes a record of the patient's history, information from the initial interview, and any tests?

database

All entries in patient records must be ______ to show the order in which they are made.

dated

Patients have the option to limit which of the following?

How much of the information in medical records is shared How the office uses their medical information

Under which circumstances may a patient's request for an amendment to PHI be denied?

If the PHI is believed to be complete If the PHI is believed to be accurate If the provider is not the original recorder of the PHI

If new patient registration information is to be entered directly into the computer, where should this be done?

In a private area

How are test results from sources outside the practice best organized?

In a section of the record designated for results

Laboratory and other test results may come from which of the following areas?

In office Independent laboratories Hospitals

The office has received laboratory and X-ray reports for a new patient. After the physician sees the reports, how should they be filed?

In the appropriate section of the file

Identify the information contained in the patient database of a Problem-Oriented Medical Record.

Information from the initial interview with the patient Results of past physical examinations

Objective

Information that comes from the physician, examinations, and test results

Which of the following entries in a patient chart indicates who performed a task?

Initials

Based on HIPAA regulations, where is the allergy sticker placed on the patient record in some medical practices?

Inside the front cover

Which of the following may be included in a treatment plan?

Instructions to the patient Medications prescribed Treatment options

Review of systems

Inventory of the body obtained by a healthcare provider through a series of questions

In what ways can a medical record play a role in medical research?

Investigating side effects with certain conditions Testing new drugs

Which of the following are included in a patient's medical record?

Occupation Medical history Address and phone number

How should each form placed in the patient record be labeled with the patient's identifying information?

On the front and back

Which of the following serve as communication tools as well as legal documents?

Patient medical records

To ensure a professional attitude and tone, which of the following pieces of information should be recorded in medical records?

Patient's chief complaint in the patient's own words Laboratory or test results Physician's observations

Which of the following are included in progress notes?

Patient's condition Treatment Problems

What type of information may be recorded in a patient's medical record?

Phone calls All procedures Follow-up care

In a court of law, who is held responsible if an employee does not chart appropriately or accurately?

Physician

Under respondeat superior, who is held responsible for the actions of the employees of a practice?

Physician

Which section of a SOAP note contains treatment options, medications, and patient education?

Plan of action

Identify the information given to the patient through an informed consent form.

Possible outcomes or side effects of treatment Any alternative treatments and possible risks Possible outcome if no treatment

Records that make it easier for a physician to keep track of a patient's progress are called

Problem-Oriented Medical Records.

Identify the pieces of information a medical assistant may obtain before an examination

Responses to treatment Vital signs Current medications

What does SOAP stand for?

Subjective, objective, assessment, plan

What is the purpose for placing a date on the top edge of the folder used for patient records and for updating the date periodically?

For easy identification of current patient records

Documenting a patient's walk down a hall as "fine" violates which "C" of charting?

clarity

To use precise descriptions and accepted medical terminology is called

clarity.

During an audit, information in a group of patient records is examined for which characteristics?

completeness accuracy

To entirely fill out all the forms used in the patient record is known as

completeness.

All the information in patient records and forms is ______, to protect the patient's privacy.

confidential

HIPAA requires that you must make a reasonable effort to communicate with a patient in a(n)

confidential manner.

Which of the following descriptions best characterize Information in patient records and forms?

confidential. PHI.

A summary of the reason a patient entered the hospital, the care the patient received in the hospital, and the outcome of the hospitalization is found in the _________

hospital discharge summary

The best place to interview a patient is _____

in a private room

Requests for an amendment to PHI must be made

in writing.

A form that verifies that a patient understands the offered treatment and its possible outcomes or side effects is called a(n)

informed consent form.

An audit performed by a member of the medical staff is known as a(n)

internal audit.

The purpose of having a patient sign an informed consent form is to ensure that the ______

patient understands the treatment offered and the possible outcomes

Important information about a patient's medical history and present condition is found in the ________

patient's health record

Assessment is the diagnosis or impression of a(n)

patient's problem.

In addition to being essential documents for patient care management, patient records are used for _____

providing patient education

The new patient registration form and the copy of the insurance card are

put in the financial records.

The information obtained from conversation with a person is

subjective.

The section of a SOAP note that contains information obtained from the patient, such as signs and symptoms, is

subjective.

Subjective or internal conditions felt by the patient are _________

symptoms

Subjective, or internal, conditions, such as pain, nausea, or headache, are called

symptoms.

Which of these is a sign of a disease or condition?

High blood pressure

Which materials may be used in creating a new patient paper medical record?

Hole punch Labels File folders Forms

Where is the diagnosis and treatment plan recorded for every patient?

Progress note

Symptom

Subjective, internal condition felt by the patient

If you are unsure about the names of procedures, medications, findings, or anything else, what should you do?

Ask the healthcare provider for clarification

Which of the following are characteristics of concise documentation?

Being brief Getting to the point Using specific medical terminology

Which of the following is NOT an advantage of electronic health records, which includes entering the new patient registration information directly into the computer?

Ability of patients to enter their own data and access the entire medical record

Which of the following apply to making corrections on medical forms?

Add the date and your initials. Cross out the old information with one line. Make a note that the information has changed.

Which of the following supplies is NOT needed to make a correction in a paper medical record?

Correction fluid

Place the steps for creating a paper medical record for a new patient in order, with the first step on top.

Create a chart label according to practice policy Place the chart label on the right edge of the folder Place the date label on the top edge of the folder Punch holes on the appropriate forms for placement in the record Place all forms in the appropriate sections of the patient's record

Which of the following is NOT one of the 6 Cs of charting?

Curtness

How can you ensure that a doctor can readily find the most recent information about a patient?

Establish a procedure for retrieving a file quickly in an emergency. Document telephone calls by recording the date and time of each call. Record the information discussed and conclusions or results.

Which of the following are examples of objective data?

Examination results Test results

Which of the following is an audit performed by an outside entity?

External audit

Documentation

Process of recording information in a medical record

Which of the following is a display of professionalism on the part of the front office medical assistant?

Greet the patient, have him sign in, and provide him with registration forms to complete.

Once registration is complete, the patient should receive a copy of which of the following?

HIPAA notice of privacy practices

Ms. Presutti completed the new patient registration form and medical history form. She comes to the desk and says she doesn't understand why she has to sign the Acknowledgment of the HIPAA Notice of Privacy Practices form. What do you tell her?

Her signature confirms that she has been given a copy of them.

In which ways should corrections be made in a medical record?

Note the date and the reason for the correction. Write corrected information above or below the original entry. Draw a single line through the error.

Sign

Objective, external factor

Place the steps for releasing medical information in order, with the first step on top.

Obtain a signed and newly dated release from the patient Make photocopies of the requested original material Call the recipient to confirm that all materials have been received

Which filing system uses the patient problem list as the source for filing within the patient medical record?

POMR

Which of the following is the most precise and clear description?

Patient got out of bed and walked 20 feet without shortness of breath.

Which of the following should be recorded when making a disclosure of a patient's Personal Health Information?

Purpose of the disclosure Date of the disclosure Summary of the information released

What should be done after a patient has been given directions?

Record the level of compliance

New patients usually complete which of the following forms first?

Registration form

Which of the following are possible uses for patient medical records?

Research, quality of care (quality control), and patient education

The type of documentation that provides an orderly series of steps for dealing with any medical case is _______

SOAP

Which approach to documentation provides an orderly series of steps for dealing with any medical case?

SOAP

The abbreviation SOB stands for which of the following?

Shortness of breath

Carefully kept medical records are valuable sources of data about which information?

Side effects Outcomes of treatment Patient responses to treatment

Why must a patient's noncompliance be documented?

So the physician can withdraw care without being liable To defend the physician from malpractice

Demographics

Specific information about a population

What is incorrect: draw a line through the original information; write the correct information on the next page of the medical record giving the date, time, your initials, and the reason for the correction?

The correction is written above, below, or in the margin near the original content.

Which document serves as the "base" for the patient medical record?

The patient medical history form

Auditing groups may review medical records to monitor which of the following?

Whether the care provided meets accepted standards Whether the fees charged meet accepted standards

What type of permission must be received when an email address is requested?

Written

Which of the following are examples of test results that must be inserted into a patient's medical record?

X-ray report Lab tests

Which of the following documents from other sources frequently become part of a patient's medical record?

X-rays, CT scan, and MRI results Lab results from private labs or hospitals Hospital discharge summaries Hospital operative notes

Complete medical records must also be _____ in order to be useful.

accurate

In order to "trust" the information in the medical record, documentation must be ____________ at all times.

accurate

Charts are usually labeled with the patient's medical record number, which is

an alphanumeric number assigned to the patient.

What is included in the assessment section of a SOAP note?

diagnosis impression

"Noncompliant" is the medical term used to describe patients who

do not follow the medical advice they receive.

The process of recording information in a medical record is called

documentation

The process of recording information in a patient's medical record is called

documentation

All information should be entered in the record at the time of a patient's visit, not days, weeks, or months later. This is called ______

due course

When a couple divorces, ______ parent(s) may sign a release form authorizing a transfer of their children's medical records.

either both

The right to sign a release-of-records form for a child when the parents are divorced belongs to _______

either the mother or the father

Individuals who are under the age of 18 and living on their own or are married, parents, or in the armed services are considered

emancipated minors.

Immediately and clearly correcting errors in the medical record helps to prevent legal problems for the physician and

ensures proper care for the patient.

One of the most important duties of a medical assistant is to _________

fill out and maintain accurate and thorough patient records

Patient records are used in medical research ______

for data regarding patient responses and side effects

Another medical assistant is with you when you notice you made an error in Ms. Jasmine's medical record. It would be good to

have her witness the correction and date and initial the patient record.

The best way to make sure the licensed practitioner sees a patient's X-ray report before filing it is to ______

have the practitioner initial the report

During an audit, records are chosen

randomly.

Dr. Girardi tries to call a patient to explain test results, but the patient does not answer the phone, and Dr. Girardi does not leave a message because he prefers to discuss the results with the patient. As the medical assistant, it is your job to __________.

record and date the call in the patient record

Test results are usually organized in ______ order in a medical record.

reverse chronological

What contains an inventory of the body obtained through a series of questions?

review of systems

The abbreviation ROS stands for

review of systems.

How many Cs are there to charting?

6

Pediatric records must be retained for

7 years after the age of majority

If a patient has requested documents from another physician be sent to your office, what must be provided?

A copy of the patient's written authorization of the release

Which of the following are true regarding how information should be updated in a patient's medical record?

Additions may require a third-party witness. Additions must be dated and initialed. Additions should be accompanied by a note explaining them.

In which section of the CHEDDAR format of documentation can the diagnosis be found?

Assessment

What does the A in SOAP documentation stand for?

Assessment

When should all information be entered in the patient's medical record?

At the time of a patient's visit

Which of the following means to examine and review a group of patient records for completeness and accuracy?

Audit

Which of the following patient details would be filed under "O" using the SOAP documentation method?

BP 160/92

Which of the following are components of the medical record?

Current medical care Personal information Medical history

According to HIPAA, a patient has the right to receive information in which manner?

During a medical appointment Any reasonable method requested by the patient

Which of the following applies to correspondence with or about a patient?

Each piece should be stamped with the date received. Each piece should be kept in the patient's medical record.

What can patient health records be used for?

Educate patients about their own condition and treatment plans

Which of the following are components of a Problem-Oriented Medical Record?

Educational plan Progress notes Problem list

Mr. Quintana is a new patient who was referred to your office by his primary care physician. When he looks through all the papers that you have given him to complete, he starts yelling at you. His doctor has all of this information and he doesn't understand why you can't get it from Dr. Hart. What should you do?

Empathize with him, offer to assist him, and remain calm and professional.

Which of the following items may included on a hospital discharge summary?

Date of admission Admitting diagnosis Date of discharge

Identify the information requested of the patient on a registration form.

Date of birth Name and address Phone numbers

Which of the following are examples of information that may be added to a patient's record?

Diagnoses Observations Test results

Which of the following are contained in an educational, diagnostic, and treatment plan?

Diagnostic workups Instructions for the patient Treatment plans

What should you do when you add new information such as a laboratory or radiology report to a patient's medical record?

Document the addition of the report and where it can be found.

SOAP

Documentation method that provides an orderly series of steps for dealing with any medical case

When documenting information from other sources, what can be included?

Documents from a hospital Patients' written release requests Documents from another physician

Which of the following is the best way to update information in a paper record?

Draw a single line through the information and add a note, the date, and your initials.

Place the steps for correcting paper medical records in order, with the first step on top.

Draw a single line through the information to be replaced Write corrected information above or below the line or in the margin Place a note near the correction stating the reason it was made Enter the date and time and initial the correction If possible have another staff member witness and initial the correction

Which statements are considered acceptable in a patient medical record?

The patient has a red rash The patient is unsteady The patient is lethargic

If changes to the medical record are not done correctly, what could be the result?

The physician may have legal problems related to alterations of the record.

In addition to your initials, the date of the correction, and the corrected content, what other information should be documented in the medical record?

The reason for the correction

In legal terms, medical records regarded as __________ may damage a provider position in a lawsuit.

convenient

Information corrected or added improperly after a patient's visit can be regarded as "______" and may damage a doctor's position in a lawsuit.

convenient

In a ______, patient information is arranged according to who supplied the data.

conventional record Source-Oriented Medical Record

Records in which a provider may find it difficult to find information on a specific diagnosis without knowing the approximate time frame of the issue is

conventional records. Source-Oriented Records.

Transcribed notes should be

dated and initialed. entered into the medical record. proofread.

After receiving a written notice of privacy practices, patients should

sign a form stating they have received the information.

External factors, such as blood pressure, rashes, or swelling, that can be seen or felt by a doctor or measured by an instrument are called

signs

Objective or external factors that can be seen or felt by the practitioner or measured by an instrument are called ________

signs